Redwood Healthcare Center LLC
3145 High Street, Oakland, CA 94619 · For profit - Limited Liability company · 44 certified beds · (510) 533-9970 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.3% | 10.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 6.4% | 4.0% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.6% | 1.2% | 2.0% | better |
| Long-stay residents with depressive symptoms | 4.7% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.5% | 1.6% | 3.3% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents whose ability to walk worsened | 11.7% | 9.8% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 4.8% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 0.0% | 4.3% | 4.7% | check this* — see note marked star below the table |
| Long-stay residents with worsening bladder/bowel control | 10.0% | 10.2% | 21.2% | typical for the state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 20.4% | 12.0% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 21.3% | 23.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 17.6% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.72 | 2.25 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 3.14 | 1.57 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
43.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 47 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 77.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 27 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.11 therapist hours per resident per day in 2026Q1 — more than 7% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 31% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 43.5%CMS range 33.7–58.4 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.6%CMS range 8.9–18.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 77.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 70.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 59.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 95.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 2.2% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.6%CMS range 3.9–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.37 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 44 beds and averages 44.1 residents a day — about 100% occupied, or roughly -0 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.43 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.63 hrs/resident/day on weekends vs 4.26 on weekdays — 15% thinner on weekends. RN hours go from 0.36 to 0.17 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 26% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.
- Potential for harm · Dcited before2026-06-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure that one of five sampled residents (Resident 1) received scheduled pain medications as prescribed by the physician when Resident 1 did not receive Hydromorphone (brand name Dilaudid, a strong pain medication) and Lidocaine Patch (a topical patch used to relieve localized pain) as ordered for multiple days, from 3/20/26 to 3/29/26.This failure to administer the prescribed pain medications resulted to Resident 1 experienced uncontrolled pain and was sent back to the hospital on 3/29/26 for pain evaluation and management.During a review of Resident 1's admission Record (AR), printed on 6/15/26, the AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of spinal cord (a long, tubular bundle of nervous tissue that runs from the brainstem down to the lower back) injury.A review of Resident 1's facility document After Visit Summary, printed on 3/20/26, indicated Resident 1 underwent a cervical (neck area) spinal fusion (a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-15 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure one of five sampled residents (Resident 1), was provided physician-ordered physical therapy (PT) five times per week. Multiple PT sessions were not provided to Resident 1 during the first three weeks of admission from 3/20/26 through 4/9/26.This failure to provide PT sessions to Resident 1 had a potential risk for delayed recovery following a spinal cord surgery. During a review of Resident 1's facility document admission Record (AR) printed on 6/15/26, AR indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of spinal cord (a long, tubular bundle of nervous tissue that runs from the brainstem down to the lower back) injury.A review of Resident 1's facility document After Visit Summary (AVS) printed on 3/20/26, AVS indicated Resident 1 underwent a cervical (neck area) spinal fusion, a surgical intervention involving the spinal cord.During a review of facility document Order Listing Report (OLR) printed on 6/15/26, OLR…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-04-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to provide adequate supervision to reduce the risk of elopement (leaving the facility unauthorized, without notifying staff), for three out of three sampled residents, when their wander guards (electronic monitoring devices, usually worn as a bracelet or anklet) were not being consistently monitored for functioning (performance of the system).1. For Resident 1, there was no documented evidence that the wander guard was monitored for functioning, every shift, from 12/15/25 until 4/17/26 (approximately four months).2. For Resident 2, there was no documented evidence that the wander guard was monitored for functioning, every shift, from 3/13/26 until 3/17/26 (13 days).3. For Resident 3, there was no documented evidence that the wander guard was monitored for functioning, multiple times on various days, in September 2025, and on 8/8/25 for functioning and placement of the wander guard.These deficient practices had the potential to place the residents at risk…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-21 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool used to direct care) for one of three sampled residents (Resident 2) was completed and coded accurately for wander guard [an electronic monitoring device, usually worn as a bracelet or anklet]. This failure placed Resident 2 at risk of not receiving the care and services appropriate to his needs, due to an inaccurate reflection of Resident 2's clinical status on the MDS assessment.Findings:During a review of Resident 2's admission Record (AR) printed on 4/16/26, the AR indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficits, and other psychoactive substance dependence.A review of Resident 2's MDS dated [DATE], indicated, Resident 2's Brief Interview for Mental Status (BIMS, an assessment to detect cognitive impairment) score of 8, indicating moderate cognitive impairment. The MDS also indicated, code '0' for Wander/Elopement…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-03-16 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure fall risk care plan interventions were implemented for two out of two sampled residents (Residents 1 and 2) who were at risk for falls, when their call lights were not within reach.This deficient practice had the potential to result in falls, injury, and harm to the residents.1.A review of Resident 1's admission record, undated, indicated Resident 1 had diagnoses that included compression fracture of the vertebra (a break in a vertebra - a bone in the spine, which may be caused by a fall or accident), and repeated falls.During an observation on 3/16/26 at 11:55 a.m. in Resident 1' room, Resident 1 was observed from the hallway. Resident 1 stood up from her bed, grabbed her walker, held onto it, and went to the bathroom unassisted. Resident 1 appeared unsteady on her feet.During concurrent observation and interview on 3/16/26 at 12:03 p.m. in Resident 1's room, Certified Nursing Assistant (CNA) 1 stated Resident 1 needed staff assistance to the bathroom as she was at risk of falling. She stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-08-23 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietician and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC S 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of qualified, full-time person to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food borne illness for 43 residents eating facility prepared foods. Findings: According to the California Code, Health, and Safety Code - HSC S 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. Subdivision (b)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-23 · tag F0677 — failed to help fully-dependent residents with daily care — patternProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to trim and clean fingernails for three out of four sampled residents when Residents 30, 32, and 33 had long fingernails with dirty substances underneath them. This failure had the potential to result in Resident 30, Resident 32, and Resident 33's poor personal hygiene and risk for infection. FINDINGS: 1a. During a review of Resident 30's Face Sheet, dated August 2024, the Face Sheet indicated, Resident 30 was admitted on [DATE] with diagnosis that includes Hemiplegia (the loss of muscle function on one side of the body) and Hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) and Diabetes (a long-term chronic disease in which the body cannot regulate the amount of sugar in the blood). During a review of Resident 30's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated July 2024, the MDS…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-08-23 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure safe storage of drugs and biologicals when: 1. Outdated or expired medications were stored in the medication room 2. A discontinued medication, including food items were stored in the medication cart These failed practices could contribute to unsafe medication use and storage in the facility. Findings: 1. During a concurrent observation and interview on 8/19/24 at 11:24 a.m., with the Infection Preventionist (IP) present, in the facility's medication room, the IP stated that the following items should have been discarded or placed in the designated discontinued or discard box next to sink inside the medication room: 1 Tube Feeding Formula, use by date 3/23/24 1 Box of COVID-19 Test Kit containing 34 test cards, kit lot number 192047, expiry date 4/30/23 3 Boxes of Sample Specimen Collection Kits containing individually packaged tubes and swabs, expiry dates 11/9/22 1 first aid kit, expiry date 1/31/22 27 Dextrose 5% Injection Bags 250 ml (milliliter), expiry dates 1/1/24 6 Normal Saline Pre-filled…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-08-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review the facility failed to meet food safety requirements for food storage and kitchen sanitation when multiple surfaces had dust, food particles and/or granular particles, two cans were dented, two items were missing use by dates, and one bag potatoes contained potatoes with roots. These failures has the potential to compromise the safety of the food served through cross contamination and cause illness or hospitalization to residents who consume it. Findings: During the initial tour of the kitchen on 8/8/22 at 10:15 a.m. with Dietary Manager 1, (DM 1), the following was observed: 1. The cart used to transport various food products to residents was observed to have a granular substance on the shelves and imbedded in the grip on the handle of the cart. 2. The stainless-steel lip on the walls surrounding the dishwasher area was observed to have substantial dust over the length of the wall mounted lip. 3. The stainless-steel counter on the dirty side of the dishwasher was observed to be very wet with food particles on the surface. 4. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-11 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction), and availability of routine and emergency drugs when: 1. Two out of 2 medication cart controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were missing signatures of the outgoing and incoming nursing shift; 2. There was no record of controlled drug destruction available upon request; 3. One out of 5 emergency kits (e-kit, a kit containing medications and supplies for immediate use during a medical emergency) was not replaced in a timely manner in accordance with the facility policy and procedures (P&P); 4. Two out of 5 e-kits expired; and 5. Expired and discontinued medications were not removed from active stock These failures had the potential for the facility to not have accurate…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 20 citations
- Potential for harm · Ecited before2022-08-11 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility had a 6.9% error rate when two medication errors out of 29 opportunities were observed during a medication pass for two of seven Residents (Residents 1 and 30). These failures resulted in medications not given in accordance with the prescriber's orders and may affect the resident's clinical condition. Findings: 1. During a medication pass observation on 8/8/22, at 10:39 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed preparing five medications, including aspirin 81 milligrams (mg, a measurement) tablet for Resident 30. A review of Resident 30's medical record indicated a physician's order, dated 5/19/21, for aspirin enteric coated (E.C., a coating formulation that allows aspirin to pass through the stomach to the small intestine before dissolving) 81 mg one tablet daily. During an interview on 8/9/22, at 12:36 p.m., with LVN 1, LVN 1 confirmed the order was for aspirin E.C. and stated she could not recall whether or not she administered the correct aspirin formulation. During an interview on 8/10/22,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-08-11 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure proper storage of medications when: 1. Medications and biologicals requiring refrigeration were not stored within manufacturer's specifications; and 2. Medication storage room and medication refrigerator temperatures were not monitored routinely per facility policy and procedure (P&P) The deficient practices had a potential for improperly stored and inadequately monitored medications, which could lead to unsafe and ineffective medication use for residents. Findings: 1. On 8/10/22 at 2:16 p.m., an inspection of the medication refrigerator with Infection Preventionist (IP) identified an internal thermometer with a temperature that measured 25 degrees Fahrenheit. Inside the refrigerator were various types of resident insulins (medication to treat elevated blood sugar) and six vials of Aplisol (an injectable used to test for tuberculosis). When asked if 25 degrees Fahrenheit was a safe temperature to store Aplisol at, IP stated she did not know. She then looked at the manufacturer's box which indicated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-08-11 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure bowel movements (BMs) were documented for three of 12 sampled residents (Residents 9, 20 and 28), on 8/1/22 through 8/5/22. This failure had the potential to result ineffective bowel management for Residents 9, 20 and 28. Findings: During a concurrent interview and record review on 8/10/22, at 2:33 p.m., with Infection Preventionist (IP), the Bowel and Bladder Log, dated August 2022 was reviewed. The log indicated that BMs were not documented for Residents 9, 20 and 28 on 8/1/22 through 8/5/22, IP stated that their policy was for Certified Nursing Assistants (CNAs) to document BMs for residents every shift in the Bowel and Bladder Log. IP stated that it was important to document resident BMs because staff wouldn't know if residents had a bowel movement, when their last bowel movement was, or if they were constipated. IP stated that resident's may have been restless due to constipation, but they wouldn't have known if their BMs…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-08-11 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review, the facility failed to ensure competency skills checks for one of three licensed nursing staff and one of two certified nurse assistants were completed. This failure had the potential for care to be provided by licensed nurses and certified nurse assistant in an unsafe and incompetent manner. Findings: During a concurrent interview and review of employee personnel files, on 8/10/22, at 2:35 p.m., with Director of Staff Development (DSD), the files indicated Licensed Vocational Nurse (LVN) 4 was hired on 5/24/20 and Certified Nurse Assistant (CNA) 2 was hired on 7/9/20. The personnel files also indicated there was no competency skills check done for LVN 4 and CNA 2 at the start of employment. DSD, indicated competency checklist was not in the employee file because it was not done. During an interview on 8/11/22, at 10:29 a.m., with the Infection Preventionist Director of Staff Development Consultant (IPDSDC), the IPDSDC confirmed, competency evaluation for LVN 4 and CNA 2 was not done. During an interview on 8/11/22, at 1:23 p.m., with the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2020-02-13 · tag F0808 — failed to follow doctor-ordered diets — widespreadEnsure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to serve therapeutic diets (diet ordered by a physician for treatment of a disease or clinical condition) as ordered for the Controlled Carbohydrate Diet (CCHO), low sodium, fortified and pureed diets for approximately 25 residents. This failure resulted in under and overserved portions of food and meals not served according to the planned menu. This also had the potential for compromised medical and nutritional status for residents. During an observation of the tray line on 2/10/20 at 11:45 a.m., and review of the winter menu for Monday Week 2, showed the following: 1. The menu indicated for 4 ounce (oz) servings. [NAME] 1 weighed 1 cooked beef patty at 3 oz for the CCHO regular diet. [NAME] 1 served 3 oz of the meat patty for the CCHO regular diets. 2. There were eight CCHO Regular diets, one 3 oz southern style meat patty and 4 oz of mashed potatoes. The menu planned was for 4 oz beef patty and 2 oz of mashed potatoes. 3. For twelve fortified diets, [NAME] 1 served 4 oz of melted butter on mashed potatoes.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2020-02-13 · tag F0580 — failed to tell family and doctor about changes — patternImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility did not notify the physician for changes in condition for four(Residents 24, 28, 194 and 297) of nine sampled residents. Resident 297 had incomplete vital sign (temperature, pulse, respiratory rate, blood pressure) records, and was subsequently sent to the hospital's emergency department (ED). The doctors were not notified when Resident 28 stopped eating, and of Residents 24 and 194's elevated blood pressure (BP). These failures resulted in the staff's failure to identify and monitor for changes in condition which had resulted in, or had the potential, for a decline in the resident's health. Findings 1. A record review of the document, Face Sheet showed Resident 24 had diagnoses that included cerebrovascular disease (condition that affects blood supply to the brain- also known as a stroke). During an observation of the medication pass, on 2/10/20 at 8:10 a.m., Licensed Vocational Nurse 2 (LVN 2) checked Resident 24's BP, which was 188/102 (normal range 120/80). LVN 2 stated, Oh, that's high, and continued to administer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2020-02-13 · tag F0813 — patternHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews and record reviews, the facility failed to provide education to families regarding food brought in from home for the residents. The facility also failed to have a system for staff to ensure food from home was re-heated to a safe temperature. This had the potential to result in burn injuries from hot food. Findings: During an interview on 2/11/20 at 9:16 AM, registered nurse 1 (RN 1) stated nursing staff reheats food in the microwave in the break room, but was not sure what temperature food is supposed to be heated. During an interview with the Dietician on 2/11/20 at 10:25 AM, the Dietician stated she does not train facility staff on the safety of food brought from home for residents. The Dietician further stated she has no involvement with how staff re-heats outside food brought into the facility for residents. She stated a re-heated food temperature of 165 degrees was too hot to eat directly, but staff was probably thinking of temperatures for other food items, such as poultry. The Dietician stated she does not provide education to families regarding food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2020-02-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure that staff performed hand hygiene after contaminating their hands while passing meal trays. This failure resulted in a certified nursing assistant passing meal trays to residents after contaminating her hands by touching her nose and lips. Findings: During an observation on 2/10/2020 at 12:30 p.m. adjacent to the dining room, Certified Nursing Assistant (CNA) 1 touched the underside of her nose and/or her lips with her hand six times while passing trays to residents in the dining room. CNA 1 did not perform hand hygiene after she touched her nose and/or mouth. During an interview on 2/10/2020 at 2:05 p.m., with CNA 1, CNA 1 stated she did not perform hand hygiene each time after she touched her nose and/or mouth with her hand while passing trays. CNA 1 stated she was supposed to perform hand hygiene after each time she touched her nose and/or mouth. During an interview on 2/11/2020 at 2:07 p.m., with Director of Staff Development (DSD), DSD stated that staff are required to do hand hygiene when passing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-02-13 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility did not treat one (Resident 2) of nine sampled residents in a dignified manner. Resident 2 asked to have his brief (diaper) changed and staff denied his request. This failure resulted in Resident 2 experiencing unnecessary distress. Findings: The record review on 2/12/20 of the document Face Sheet showed the facility admitted Resident 2 on 8/8/19. A record review of the document used to assess patients condition and care needs titled, MDS (minimum data set) 3.0 dated 1/31/20, showed Resident 2's diagnoses included dementia. (symptoms that affects memory, thinking, and social abilities, enough to interfere with daily life). The record review of the nursing Departmental Notes dated 1/17/20 to 1/23/20 showed Resident 2 was, Alert and responsive. A record review of the plan of care dated 8/8/19 indicated Resident 2 was dependent on staff for assistance with toileting, was unable to walk, and incontinent of bowel and bladder (unable to control urine or bowel movements), and was at risk for skin breakdown. The interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-02-13 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide personal hygiene care in a timely manner for one (Resident 2) of nine sampled residents. Resident 2 gestured to have his brief (diaper) changed and staff did not immediately respond. This failure resulted in Resident 2 experiencing discomfort and had the potential for skin breakdown. Findings: A record review of the document used to assess patients condition and care needs titled, MDS (minimum data set) 3.0 dated 1/31/20, showed Resident 2's diagnoses included dementia (symptoms that affects memory, thinking, and social abilities, enough to interfere with daily life). The record review of the nursing Departmental Notes dated 1/17/20 through 1/23/20 showed Resident 2 was, Alert and responsive. A record review of the care plan titled, Communication problem dated 8/8/19 indicated one goal was for Resident 2 to communicate needs daily. The interventions included for staff to become familiar with nonverbal cues, gestures and body language . A record review of the plan of care dated 8/8/19 indicated Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-02-13 · tag F0726 — failed to have competent, trained nursing staff — isolatedEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews, and record review, the facility failed to ensure competencies and skills for one of three sampled licensed nursing staff. This failure resulted in the licensed nurse not receiving the required skills competency check to ensure safe care of residents. [Refer to F 726 and F 759] Findings: During a record review on 02/13/20, the employee personnel file for LVN 2, hired 2/3/20, contained a document titled, Nurse Assistant Orientation & Competency Evaluation Nursing Skills Performance Satisfactory Completion dated 2/3/20. This document had no signature from LVN 2 or the skills evaluator, and the skills checklist was not completed. There was no licensed nursing skills check list in LVN 2's employee file. During an interview on 2/13/20 at 8:04 AM, the Director of Staff Development (DSD) stated the facility does a skills checklist for new nursing staff, and the skills checklist is done annually at time of hire. DSD further stated the competency is done by observing if staff are following protocols and watching nursing care being given to residents. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-02-13 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility did not maintain a medication error rate of 5% or less. The medication error rate was 7.69%. Resident 17 was administered the incorrect amount of pain medication. This failure resulted in the potential for ineffective pain relief. Findings: Record review on 2/10/20 of the document, Administering Medications, dated 2012, showed Medications shall be administered in a safe and timely manner, and as prescribed. Record review of the document, Face Sheet showed Resident 17 had diagnoses that included lung disease and muscle weakness. Record review of the document, Medication Administration Record dated 11/5/19, showed Resident 17 was to receive, Voltaren (antiinflammatory) 1% gel. Give 4 gms (grams) BID (twice a day) for pain in hands. Resident 17 also received, Gabapentin 600 mg tablet, give 1.5 tab (tablet) by mouth TID (three times a day) for neuropathy (a disease of the body's nerves which can cause numbness or weakness). During an observation of the medication pass on 2/10/20 at 8:10 a.m., Licensed Vocational Nurse 2…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-02-13 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, licensed nursing staff did not store medication in a secured manner. A lidocaine patch (pain reliever] was left unattended on top of the medication cart. This failure had the potential for unauthorized access and use of medication by other persons which could result in harm. Findings: During an observation of the medication pass on 2/12/20 at 9:30 a.m., Licensed Vocational Nurse 2 (LVN 2) lifted the inoperable laptop computer from the top of the medication cart, and went to the nurses station to exchange it for another one. A lidocaine patch which had been underneath the laptop was left unattended. In a concurrent interview, LVN 2 confirmed the lidocaine patch was underneath the laptop because she was hiding, it and saving it to give to another resident. In an interview on 2/12/20 at 9:40 a.m., the Director of Nursing (DON) verified the lidocaine patch was left unattended on top of the medication cart. DON stated if a nurse leaves the cart for any reason, all medication must be locked and secured within the medication cart. A record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-02-13 · tag F0802 — failed to prepare enough nourishing food — isolatedProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure competencies and skills for kitchen staff. This failure resulted in the potential for food borne illness, inaccurate temperature testing of cooked foods, and physician ordered therapeutic diets not being made correctly by kitchen staff. Findings: During an observation on 2/10/20 at 11:45 AM, [NAME] 1 did not fill the scoop fully for the pureed diets during lunch tray line. There was not enough pureed meat for all residents receiving pureed diets. During an interview on 2/10/20 at 12:45 AM, the Dietary Manager (DM) stated [NAME] 1 should have made more pureed food to ensure residents were given the amount of pureed food as ordered by their physician. During a record review of employee file for [NAME] 1, employed since 2018, there was no orientation, no evaluation, or competency training contained in the employee file. During a record review of the Food Service in-services for dietary staff, there was no signature for [NAME] 1 on the attendance sign-in sheet for the months of 1/2019, 2/20/19, 11/2019,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2020-02-13 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and record reviews, the facility failed to ensure food for residents was prepared under sanitary conditions. This failure had the potential to cause food borne illness. Findings: During an observation on 2/10/20 at 10:23 AM, [NAME] 1 used a soiled cleaning towel with debris present to wipe down the kitchen food preparation counters, then placed the counter with container of cooked food on top of it. [NAME] 1 then picked up the soiled towel from the counter and placed it in the sink near the raw meat was thawing in a pan. [NAME] 1 left the soiled towel in the sink for a couple of minutes before removing the towel from the sink. [NAME] 1 did not clean the sink after removing the soiled towel. During a record review of the facility's policy and procedure titled, Cleaning and Sanitizing(undated) indicated, 1. Food contact surfaces must be cleaned .b. each time there is a change from working with raw foods to working with ready-to eat food, and 7. Food contact surfaces and utensils must be sanitized before each use. During a record review of the facility's policy and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2020-02-13 · tag F0814 — failed to dispose of garbage properly — isolatedDispose of garbage and refuse properly.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and interview, the facility failed to ensure that one of two dumpsters were closed shut. This failure resulted in unsanitary conditions and attracted flying pests. During an observation on 2/10/20 at 10:15 a.m., one of two dumpsters was left open and overfilled with garbage that had insects flying above it. During an interview on 2/11/20 at 9 a.m. with Maintenance Director, he stated that the garbage is picked up on Monday, Wednesdays and Fridays. No trash was picked up on Monday. Review of the facility's policy titled, Food-Related Garbage and Rubbish Disposal indicated, all garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored. Outside dumpsters .will be kept closed and free of surrounding litter.
- Potential for harm · D2020-02-13 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure for one of eight sampled residents (Resident 20), that the call light was in working order. This failure resulted in Resident 20 being unable to turn the call light on to request help from facility staff. Findings: During an observation and interview, on 2/11/2020 at 8 a.m., Resident 20 stated her call light was broken. The button to press and turn on the call light was missing. During an immediate interview on 2/11/2020, at 8 a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated the call light was not broken and retrieved the call light from underneath the blankets and confirmed Resident 20's call light was broken. CNA 3 notified the Maintenance Director (MTN). During an interview and record review on 2/11/2020 at 8:10 a.m., MTN stated Resident 20's call light was broken and he replaced it. MTN provided the weekly maintenance log for the facility's call light system, and Resident 20's call light was checked and working on 2/7/20. MTN further stated the CNAs are supposed to write down anything…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2024-08-23 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to provide 27 of 43 residents in resident Rooms A, B, C, D, E, F, G, H, and I with at least 80 square (sq) feet (ft) of living space per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, and lack of sufficient space for residents to have personal belongings at the bedside. Findings: During a record review of the Client Accommodations Analysis, dated 8/19/24, the following resident rooms and corresponding square footage were identified: Room A was a total of 216.2 sq. ft. and had three beds making 72 sq. ft. of space per resident. Room B was a total of 214.28 sq. ft. and had three beds making 71.42 sq. ft. of space per resident. Room C was a total of 216.04 sq. ft. and had three beds making 72 sq. ft. of space per resident. Room D was a total of 217.04 sq. ft. and had three beds making 72.34 sq. ft. of space per resident. Room E was a total of 217.88 sq. ft. and had three beds making 72.62 sq. ft. of space per resident. Room F was a total…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2022-08-11 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. The facility had nine resident rooms (room A, B, C, D, E, F, G, H, I) with a total of 27 licensed beds that were occupied by 25 residents, that provided less than 80 square feet (sq. ft.) per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, and lack of sufficient space for residents to have personal belongings at the bedside. Findings: During observations between 8/8/2022-8/11/2022, the following resident rooms and corresponding square footage were identified: Room A had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. Room B had three beds that measured 17 ft. by 12.6 ft., providing 70.83 sq. ft. per resident. Room C had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. Room D had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · Bcited before2020-02-13 · tag F0912 — patternProvide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide 23 of 43 residents in resident Rooms 9,10,11,12,14,15,16,18, and 19 with at least 80 square (sq) feet (ft) of living space per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff, and lack of sufficient space for residents to have personal belongings at the bedside. Findings: room [ROOM NUMBER] had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.6 ft., providing 70.83 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.7 ft., providing 71.31 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.8 ft., providing 71.89 sq. ft. per resident. room [ROOM NUMBER] had three beds that measured 17 ft. by 12.7…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CRYSTAL SOLORZANO — 9 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 2.0 | +2.0 vs chain |
| Health inspection | 4 of 5 | 2.1 | +1.9 vs chain |
| Staffing | 3 of 5 | 2.9 | +0.1 vs chain |
| Quality measures | 4 of 5 | 3.3 | +0.7 vs chain |
The other 8 homes this chain runs (chain average 2.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| RHCST LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 24% | since 08/15/2024 |
| COHEN, RACHEL | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | 51% | since 05/01/2026 |
| DIONISIO, PAOLA | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 24% | since 08/15/2024 |
| RUST, JADEN | Individual | INDIRECT OWNERSHIP INTEREST | — | since 08/15/2024 |
| CHAVARRIA, EVA | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2024 |
| RENEW HEALTH CONSULTING SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/17/2023 |
| KAUR, AMANDEEP | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/23/2023 |
| NG, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/28/2019 |
| SHARMA, VATSALA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 08/17/2023 |
| GATEWAYS REHABILITATION CENTER II LLC | Organization | ADP OF THE SNF | — | since 08/17/2023 |
CMS files one row per role, so the 18 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 74% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $349K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555499. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-08-23, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.